A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds each, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction, nadir after the peak of the contraction, and a return to baseline after the contraction is over.
Which of the following actions should the nurse take?
Increase the rate of infusion of the IV oxytocin.
Decrease the rate of infusion of the maintenance IV solution.
Discontinue the infusion of the IV oxytocin.
Slow the client's rate of breathing.
Slow the client's rate of breathing.
The Correct Answer is C
Choice A rationale
Increasing the rate of infusion of IV oxytocin in the presence of abnormal fetal heart rate decelerations is contraindicated. It may exacerbate uterine hyperstimulation, further compromising fetal oxygenation.
Choice B rationale
Decreasing the rate of infusion of the maintenance IV solution will not address the issue of uterine hyperstimulation or abnormal fetal heart rate decelerations. The focus should be on managing oxytocin administration.
Choice C rationale
Discontinuing the infusion of IV oxytocin is appropriate due to uterine tachysystole and associated fetal heart rate decelerations. This helps reduce uterine contractions and allows for fetal recovery, improving oxygenation.
Choice D rationale
Slowing the client's rate of breathing is not related to managing uterine contractions or fetal heart rate decelerations. The intervention should directly address the cause of the decelerations, which is oxytocin-induced hyperstimulation. .
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Correct Answer is A
Explanation
Choice A rationale
Anaphylactoid syndrome of pregnancy (also known as amniotic fluid embolism) occurs when amniotic fluid, fetal cells, hair, or other debris enter the mother's bloodstream, triggering
a serious reaction. It can cause sudden shortness of breath, cardiovascular collapse, and other severe symptoms immediately after a rupture of membranes and is a rare but critical
obstetrical emergency.
Choice B rationale
Abruptio placentae involves the premature separation of the placenta from the uterine wall, which leads to bleeding and potential fetal and maternal distress. However, it does not
typically present with sudden cardiorespiratory collapse or shortness of breath immediately following membrane rupture.
Choice C rationale
Uterine rupture refers to a tear in the wall of the uterus, usually due to trauma, labor stress, or previous surgical scars. While it is a severe condition, it usually presents with
abdominal pain, vaginal bleeding, and fetal distress rather than sudden respiratory failure.
Choice D rationale
Disseminated intravascular coagulation (DIC) is a condition affecting blood clotting processes, often secondary to other conditions like severe preeclampsia, sepsis, or trauma. It
generally presents with bleeding and clotting issues but not sudden respiratory or cardiovascular collapse.
Correct Answer is C
Explanation
Choice A rationale
Dexamethasone is a corticosteroid and is not used for treating ectopic pregnancy.
Choice B rationale
Clomid (clomiphene citrate) is used to stimulate ovulation, not to treat ectopic pregnancy.
Choice C rationale
Methotrexate is a chemotherapeutic agent that effectively stops the growth of ectopic pregnancy cells, allowing the pregnancy tissue to be reabsorbed by the body.
Choice D rationale
Progesterone supports pregnancy and is not used to treat ectopic pregnancy.